Information Collection

Agent/Broker Eligibility and Consent Documentation

IC 257714 under ICR 202304-0938-025 · OMB 0938-1438.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0938-1438 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form CMS-10840 Agent/Broker Eligibility and Consent Documentation	Form
CMS-10840 CMS Model Consent Form for Marketplace Agents and Broker CMS-10840_Agent-Broker_Consent_Appenidx_A_Consent_Form.pdf	Form
CMS-10840 CMS Model Consent Form for Marketplace Agents and Broker CMS-10840_Agent-Broker_Consent_Appenidx_A_Consent_Form.pdf	Form

IC Title:

Agent/Broker Eligibility and Consent Documentation

Agency IC Tracking Number:

CCIIO - 10840

Is this a Common Form? No

IC Status: Modified

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation: 45 CFR 155.220

Information Collection Instruments:

table that charts list of instruments
Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	CMS-10840	CMS Model Consent Form for Marketplace Agents and Brokers	CMS-10840_Agent-Broker_Consent_Appenidx_A_Consent_Form.pdf		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 4,947,909

Number of Respondents for Small Entity: 0

Affected Public: Private Sector

Private Sector: Businesses or other for-profits

Percentage of Respondents Reporting Electronically: 100 %

table that charts list of burden
	Approved	Program Change Due to New Statute
Annual Number of Responses for this IC	4,947,909	4,947,909
Annual IC Time Burden (Hours)	841,145	841,145
Annual IC Cost Burden (Dollars)	26,372,355	26,372,355

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
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Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.